Wiki bicep release surgery question

[donsgirl1015]

I have an op report that is puzzling me ~

my provider has documented that "you could see she had a fairly significant superior labral tear. we went ahead and released the bicep tendon at that time. we debrided around the superior labrum as well"

is that an appropriate connection? I can't find any information to support a bicep tendon release procedure for a slap tear diagnosis.

has anyone billed for this cpt/dx before?

thank you,
melissa

 

[AlanPechacek]

For what it is worth, ICD-10 does not have a code for what would be considered Chronic, Degenerative Superior Labral Tear, i.e. "Chronic" SLAP. If the patient had no history of previous dislocation or instability of her shoulder, or anything compatible with Use, Overuse, or Pressure, then about the best code is M75.8 _: "Other" Shoulder Lesion.
As for the procedure for treatment of Chronic degenerative tearing of the superior labrum, a SLAP Repair (29807) would not apply since there was no "repair." Often times in this situation, rather than doing a "repair," the Biceps Tendon is released/tenotomized from the superior labrum but a Biceps Tenodesis (29828) is done more often rather than just a release alone. There isn't a code for Arthroscopic Biceps Tenotomy alone, so it may have to be included/incorporated into his "debridement" procedure, 29822 if limited, or 29823 if there was more extensive debridement than just this area. Your note doesn't say what else was found and/or done other than debriding the damaged superior labrum.
This is the best I can offer with the information provided. I hope it helps some.

Respectfully submitted, Alan Pechacek, M.D.

 

[Orthocoderpgu]

What your doc is saying does make sense

The long head of the biceps becomes anchored as it surrounds the joint. The tendons anchor can get pulled off the glenoid which causes fraying. This fraying can be debrided (smoothed out). If the surgeon decides that a tenodesis needs to be done, they will clip the long head tendon and debride the stump of the tendon. This debridement is included with the procedure and not part of 29822 or 29823. This procedure treats the SLAP lesion by taking the pressure off of the SLAP area or anchor. If the biceps tendon is too degenerative for a tenodesis procedure, then it will just be cut.

https://www.shoulderdoc.co.uk/section/15